The Silent Killers

Kind attn: Mr. Divesh Nath
For Woman’s Era

Name: Sudha Hariharan
A/c No: 424
Date: April 26, 2010



Arthritis in Youngsters, Osteoporosis in Women …The Silent Killers


Osteoporosis is a condition characterized by a decrease in the density of bone, decreasing its strength and resulting in fragile bones. Osteoporosis literally leads to abnormally porous bone that is compressible, like a sponge. This disorder of the skeleton weakens the bone and results in frequent fractures (breaks) in the bones.


In the U.S., 44 million people have low bone density (10 million have osteoporosis and 34 million have osteopenia. The situation is even worse in Asian patients. One in two Caucasian women will experience a bone fracture due to osteoporosis in her lifetime. Approximately 20 per cent of those who experience a hip fracture will die in the year following the fracture. Only one-third of hip-fracture patients regain their pre-fracture level of function.

It is a rare adult who has never experienced some form of arthritis or rheumatism. These diseases are very common and among the oldest known to man. It is only of late that the magnitude of the problem been appreciated. Consequently a great deal of new knowledge, understanding and treatment is now available. Though a complete cure is not available, treatment is helpful specially if started within the first 6 months of onset. Arthritis need not be crippling.

A recent pan-India health survey reveals that osteoarthritis has emerged as the numero uno ailment in India, even trouncing traditional heavyweights like AIDS, diabetes, cancer and hypertension. The survey conducted by TNS, an ISO-accredited market research agency in Delhi, was carried out across a swathe of 15 cities - Delhi, Lucknow, Ludhiana, Jaipur, Varanasi, Chennai, Bangalore, Hyderabad, Cochin, Kolkata, Patna, Mumbai, Ahmedabad, Nagpur and Indore.

According to the study, in the age band of 25 to 35 years, osteoarthritis is the second most prevalent disease in India after diabetes. The study showed that despite this, awareness amongst Indians about the bone ailment is almost nil as compared to high profile diseases like cancer, AIDS and diabetes. The prevalence of doctor-diagnosed arthritis is projected to increase to nearly 25 percent of the adult population by the year 2030.

Almost one-third of all cases will be in working-age adults, those 45 to 64 years old. This large increase poses a major challenge to the health care and public health systems. The World Health Organization (WHO) estimates that 70 million Indians are victims of arthritis. According to the US-based Arthritis Foundation, 80 per cent of the 50-plus people in the world will experience arthritis in one of its many hundred forms.

A study published (in the Journal of Community Medicine Vol. 1, No.1, January 2007) showed significant difference in the prevalence of osteoarthritis in elderly of rural and urban areas. The low prevalence of osteoarthritis in rural elderly could be due to differences in their life style. Rheumatoid Arthritis has a prevalence of 0.75 per cent; projected to the whole population, this would give a total of about 7 million patients in India.

Dr. Kaushal Malhan, Hip and Knee Surgeon, Fortis Hospital sheds light on the causes, symptoms and the most hi-tech and effective lines of treatment .

“Statistics have shown that over the past several years, the age of onset of osteoarthritis has been steadily decreasing. Also secondary arthritis is being commonly seen in younger people. The number of young patients with endstage joint disease seeking a satisfactory remedy is going up day by day. These patients are beyond the scope of medicines and need surgical treatment. These are high- demand patients who need high -performance surgery. Conventional joint replacement surgery is therefore less appropriate. The innovative tissue and bone sparing techniques we have been doing at our centre are very appropriate for this group of patients” says Dr. Kaushal Malhan.

Ketan Mhatre (33) a young IT professional says “Since the age of 24, when I was first diagnosed with rheumatoid arthritis, I thought I had no hopes but to live with the pain and compromised gait, till I consulted Dr. Malhan who gave me hope of a new beginning with specialized tissue preserving knee and hip surgery. He understood the needs of a young person like me and with advanced surgery truly gave a new meaning to my life” Ketan has undergone a hip resurfacing and bilateral knee replacement with tissue preserving technique.

Dr. Malhan, along with his team performed the hip resurfacing and knee replacement surgery on Ketan with specialised tissue- preserving methods to treat his worn out joints. Ketan Mhatre who lives with his wife and parents in Thane was suffering from severe pain in his joints. His hip and knee joints were damaged to the extent that they made a cracking sound while walking. He was unable to stand and walk due to excruciating pain. Medicines of all sorts were not helping him as his joints were totally damaged by arthritis. With endstage secondary arthritis in almost all his weight- bearing joints, Ketan’s life and career was crippled. This disease had completely compromised his physical and social life and posed a threat to his career.

“Ketan’s problems began with the onset of inflammatory type of joint arthritis which started to damage a number of joints in his body especially those of the lower limbs. In spite of good medical treatment , the disease progressed unabatedly and caused severe damage to the right hip and both knees. He was unable to stand straight and walk. Since the joints were completely destroyed there was no option but to consider replacement surgery. In view of his young age I decided to replace his joints with techniques that would preserve as much as possible. I did a bone conserving hip resurfacing surgery and bilateral tissue preserving total knee replacement. Both knees had to be done in one sitting because of the extreme deformity. Doing one at a time would not allow proper rehabilitation and Ketan was in no condition to allow a long drawn wait and rehabilitation,” explains Dr. Malhan.

What exactly is osteoporosis?
Normal bone is composed of protein, collagen, and calcium all of which give bone its strength. Collagen is the term applied to the supporting connective tissues of the body. It would be correct to think of bone structure as being similar to a column made of metal girders (protein chains) and concrete (calcium or hydroxyapatite). Osteoporosis represents a reduction in both of these and therefore damage to the microstructure of bone and not simply deficiency of calcium as is commonly believed. Deficiency of calcium and vitamin D can aggravate osteoporosis but is not the main and only cause. Naturally, just taking calcium and vitamin D to treat osteoporosis is not enough.

Are there any obvious symptoms that manifest with the onset of the disease?

Osteoporosis can be present without any symptoms for decades because it does not cause symptoms until bone fractures. Moreover, some osteoporotic fractures may escape detection for years when they do not cause symptoms. Therefore, patients may not be aware of their osteoporosis until they suffer a painful fracture. The symptom associated with osteoporotic fractures usually is pain and disability depending on the location of the fracture. Osteoporosis is therefore often called the “the silent killer”.

Do women have lower bone density?

Bone mass (bone density) is determined by the amount of bone present in the skeletal structure. Generally, higher the bone density, stronger the bones. Estrogen, a hormone in women is important in maintaining bone density. When estrogen levels drop after menopause, loss of bone density accelerates. During the first five to 10 years after menopause, women can suffer up to 2-4 per cent loss of bone density per year! This can result in the loss of up to 25-30 per cent of their bone density during that time period. Accelerated bone loss after menopause is a major cause of osteoporosis in women. Hormone replacement therapy post menopause prevents this loss but is of no major help once the window period of 6 yrs post menopause is over. The male hormone testosterone also maintains bone density in men and senile osteoporosis i.e. due to ageing may be seen in men after 70 yrs age due to reduction in the hormone levels. Also steroids and some medicines may predispose to osteoporosis.

What are the common risk factors women face?

Female gender, caucasian or Asian race, thin and small body frame, family history of osteoporosis, cigarette smoking, excessive alcohol consumption, lack of exercise, diet low in calcium and poor nutrition, malabsorption. Low estrogen levels in women (such as occur in menopause or with early surgical removal of both ovaries), low testosterone levels (hypogonadism), chemotherapy that can cause early menopause due to its toxic effects on the ovaries, amenorrhea (loss of the menstrual period) in young women associated with low estrogen and osteoporosis.

Amenorrhea can occur in women who undergo extremely vigorous exercise training and in women with very low body fat, for example, women with anorexia nervosa, chronic inflammation, due to chronic diseases such as rheumatoid arthritis or liver diseases, immobility, such as after a stroke, or from any condition that interferes with walking, hyperthyroidism, a condition wherein too much thyroid hormone is produced by the thyroid gland or is ingested as thyroid hormone medication. Certain medications can cause osteoporosis. These include long-term use of anti-seizure medications such as phenytoin and phenobarbital, and long-term use of oral steroids.

How can one detect the onset of osteoporosis?

A routine X-ray can reveal osteoporosis of the bone because the bones appear much thinner and lighter than normal bones. Unfortunately, by the time X-rays can detect osteoporosis, at least 30 per cent of the bone has already been lost. In addition, X-rays are not accurate indicators of bone density.

What are the treatment options available?
The best treatment for osteoporosis is prevention. Increase the bone mass as much as possible in the formative years. Impact loading exercise like brisk walking and adequate calcium, vitamin D and proteins in a healthy well balanced diet helps. Reduce risk factors as mentioned above. At risk people should get themselves screened.

In patients for established disease, treatment with calcium and vitamin D alone is not enough. One has to supplement with special osteoporosis medicines like antiresorptives e.g. bisphosphonate or bone forming drugs like teriparatides depending on which is suitable. Patients with low hormone levels will benefit from hormone replacement therapy taken after consultation the doctor.

Can you tell us a little more about preventive measures and treatments available?

Treatment of osteoporosis consists of treatment of the condition itself which is medical and its complications, which is a combination of medical and surgical treatment The best treatment is to prevent the disease. This can be done by increasing the bone mass during the first three decades of life with a good healthy diet containing adequate protein, calcium and vitamin D. Milk, eggs, nuts, cheese, curds and lots of sunshine are good sources of these. Calcium and vitamin D tablets can be taken to supplement the diet. High impact loading exercise will increase the skeletal bone mass and a daily brisk walk is useful.

The same steps are useful for patients of established osteoporosis but in addition they need anti -osteoporosis medication. This can be in the form of antiresorptives which prevent further bone mass deterioration and hence indirectly increase the overall bone stock, and anabolic drugs like teriparatides that cause production of more bone and increase the strength of the skeleton.

Are there any measures for perimenopausal and early menopausal women?

Perimenopausal and early menopausal women may consider the option of hormone replacement after discussing with their doctor. Such therapy is however useful in only the first 6-7 yrs after menopause and needs to be continued lifelong to maintain the bone mass. If started after 6-7 yrs post menopause then it of little benefit. Women who have lost their normal hormonal support due to removal of ovaries or other problems early in life can consider artificial hormone replacement therapy. Surgery is needed to mend complications like fractures due to weak bones. Common fractures are those of the hip, wrist and spine. Treatment options may range from simple plaster treatment to fixation of fractures with metal implants or joint replacement options. Non- healing painful spinal fractures may be tackled with minimally invasive techniques like vertebroplasty.